| Values |
| Female |
| Male |
| prefer not to disclose |
| X |
| Field Name | Data Type | Value |
| Program | Dropdown | Podiatric Physician and Surgeon |
| Professions | Dropdown | Podiatric Physician and Surgeon |
| Podiatric Physician And Surgeon Limited License | Checkbox | True |
| Field Name |
| Alternate Names: |
| Field Name | Data Type | Value |
| Alternate Names: | Text | test Alternate |
| Field Name | Data Type |
| Street | Text |
| City | Text |
| Country | Dropdown |
| State | Dropdown |
| Zip Code | Text |
| County | Text |
| Field Name | Data Type |
| Street | Text |
| City | Text |
| Country | Dropdown |
| State | Dropdown |
| Zip Code | Text |
| County | Text |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| Field Name | Data Type |
| State | Dropdown |
| Field Name | Data Type | Value |
| Country | Dropdown | Afghanistan |
| Field Name | Data Type |
| State | Text |
| Error Message |
| Error: 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? is required. |
| Error: 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? is required. |
| Error: 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism? is required. |
| Error: 4. Are you currently engaged in the illegal use of controlled substances? is required. |
| Error: 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? is required. |
| Error: 6a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? is required. |
| Error: 6b. Diverted controlled substances or legend drugs? is required. |
| Error: 6c. Violated any drug law? is required. |
| Error: 6d. Prescribed controlled substances for yourself? is required. |
| Error: 7. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? is required. |
| Error: 8. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? is required. |
| Error: 9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid action by a state, federal, or foreign authority? is required. |
| Error: 10. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? is required. |
| Error: 11. Have you had hospital privileges, medical society, other professional society or organization membership revoked, suspended, restricted or denied? is required. |
| Error: 12. Have you ever been the subject of any informal or formal disciplinary action related to the practice of medicine? is required. |
| Error: 13. To the best of your knowledge, are you the subject of an investigation by any licensing board as to the date of this application? is required. |
| Error: 14. Have you ever agreed to restrict, surrender, or resign your practice in lieu of or to avoid adverse action? is required. |
| Error: 15. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? is required. |
| Field Name | Data Type | Value |
| 1a. Please explain medical condition. | Textarea | test medical condition |
| 1b. Please explain how your treatment has reduced or eliminated the limitations caused by your medical condition. | Textarea | Test reduced limitations |
| 1c. Please explain how your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. | Textarea | test manner of practice |
| Field Name | Data Type | Value |
| 2a. Chemical Substance Explanation | Textarea | test Chemical Substance |
| Field Name | Data Type | Value |
| 3a. Diagnosis Explanation | Textarea | Test Diagnosis Explanation |
| Field Name | Data Type | Value |
| 4a. Controlled Substances Explanation | Textarea | Test illegal issue |
| Bold Text |
| Note: If you answer 'yes' to any of the remaining questions, provide an explanation and certified copies of all judgements, decisions, orders agreements and surrenders. The department does criminal checks on all applicants. |
| Field Name | Data Type | Value |
| 5a. Conviction Explanation | Textarea | Test Conviction Explanation |
| Bold Text |
| Note: Since you answered 'yes' to question 5, you must send certified copies of all court documents related to your criminal history with your application. If you do not provide the documents, your application is incomplete and will not be considered. If you have been granted certificate(s) of restoration of opportunity, please provide a certified copy of each certificate. |
| To protect the public, the department considers criminal history. A criminal history may not automatically bar you from obtaining a credential. However, failure to report criminal history may result in extra cost to you and the application may be delayed or denied. You will have the ability to upload documents on the supporting documentation step in this application. |
| Field Name | Data Type | Value |
| 6a. Controlled Substance Legal Explanation | Textarea | Test Controlled Substances Explanation |
| Field Name | Data Type | Value |
| 6b. Criminal Proceedings Explanation | Textarea | Test Criminal Proceedings |
| Field Name | Data Type | Value |
| 6c. Drug Law Violations Explanation | Textarea | Test Drug Law |
| Field Name | Data Type | Value |
| 6d. Self Prescribed Controlled Substance Explanation | Textarea | Test Self Prescribed |
| Field Name | Data Type | Value |
| 7a. Violation of State or Federal Law Explanation | Textarea | Test Violation of state |
| Field Name | Data Type | Value |
| 8a. License, Certificate, Registration Issue Explanation | Textarea | Test License Certificate |
| Field Name | Data Type | Value |
| 9a. Surrender Explanation | Textarea | Test surreender explanation |
| Field Name | Data Type | Value |
| 10a. Civil Judgement Explanation | Textarea | Test Civil Judgement |
| Field Name | Data Type | Value |
| 11a. Please explain | Textarea | Test 11Vulnerable persons |
| Field Name | Data Type | Value |
| 12a. Please explain | Textarea | Test 12person disqualification |
| Field Name | Data Type | Value |
| 13a. Please explain | Textarea | Test 13 person disqualification |
| Field Name | Data Type | Value |
| 14a. Please explain | Textarea | Test 14 person disqualification |
| Field Name | Data Type | Value |
| 15a. Vulnerable Persons Disqualification Explanation | Textarea | Test 15 person disqualification |
| Field Name | Data Type | Value |
| 1. Enter your National Provider Identifier (NPI) Number if available. | Text | 123456 |
| Error Message |
| NPI is 10 digits. |
| Field Name | Data Type | Value |
| 1. Enter your National Provider Identifier (NPI) Number if available. | Text | 1234567890 |
| Error Message |
| NPI is 10 digits. |
| Link |
| Add |
| Error Message |
| Please add at least one other license, certificate or registration |
| Link |
| Add |
| Error Message |
| Error: Country is required. |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| Error Message |
| Error: State or Province is required. |
| Error: Profession is required. |
| Error: Credential Type is required. |
| Error: Credential Number is required. |
| Error: Issue Date is required. |
| Error: Expiration Date is required. |
| Error: Is this credential currently in an active status? is required. |
| Error: How did you receive this credential? is required. |
| Field Name | Data Type | Value |
| How did you receive this credential? | Dropdown | Grandparented |
| State or Province | Dropdown | Alabama |
| Profession | Text | Test Doctor |
| Credential Type | Dropdown | Temporary |
| Credential Number | Text | 12345678 |
| Issue Date | Date | Today - 100 |
| Expiration Date | Date | Today - 0 |
| Field Name | Data Type | Value |
| Credential Number | Text | 23456789 |
| Field Name | Value |
| Credential Number | 23456789 |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| How did you receive this credential? | Dropdown | Grandparented |
| State or Province | Dropdown | Alabama |
| Profession | Text | Test Doctor |
| Credential Type | Dropdown | Temporary |
| Credential Number | Text | 12345678 |
| Issue Date | Date | Today - 100 |
| Expiration Date | Date | Today - 0 |
| Field Name | Data Type | Value |
| Country | Dropdown | United States |
| How did you receive this credential? | Dropdown | Grandparented |
| State or Province | Dropdown | Alabama |
| Profession | Text | Test Doctor |
| Credential Type | Dropdown | Temporary |
| Credential Number | Text | 12345678 |
| Issue Date | Date | Today - 100 |
| Expiration Date | Date | Today - 0 |
| Error Message |
| Error: Select one: is required. |
| Text |
| After you submit your application, you’ll be able to print the |
| Podiatric Postgraduate Training Investigative Letter |
| Once printed, provide to the Program Director of your postgraduate program. Ask them to complete the form and return to the Department of Health. |
| Error Message |
| Error: Post Graduate Training Program Name is required. |
| Error: Specialty is required. |
| Error: Start Date is required. |
| Error: End Date is required. |
| Field Name | Data Type | Value |
| Post Graduate Training Program Name | Text | Test Program |
| Specialty | Text | Test Specialty |
| Start Date | Date | Today - 50 |
| End Date | Date | Today - 0 |
| Current | Checkbox | True |
| Field Name |
| End Date |
| Text |
| Based on your responses the following documentation is needed to support your applications review. If you do not have these listed documents currently you can submit the application and return to this page to upload the documents. Please note that once you upload a document you cannot delete it. A review must occur first before a replacement document can be uploaded. This may delay the processing time of your application. Please double check the document is correct before uploading. |
| Are you the spouse or registered domestic partner of military personnel? |
| Other License, Certifications or Registrations |
| Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a health care profession? |
| Please attach certified copies of all court documents related to your criminal history with your application. |
| Please attach copies of all judgements, decisions, and agreements. |
| Text |
| Postgraduate Training Investigative Letter |
| Limited License Postgraduate Training Verification Letter |
| Additional Information |
| Error Message |
| Please check the checkbox. |
| Field Name | Data Type | Value |
| I agree. | Checkbox | true |
| Text |
| I understand the Department of Health may require more information before deciding on my application. The department may independently check conviction records with state or federal databases. |
| I authorize the release of any files or records the department requires to process this application. This includes information from all hospitals, educational or other organizations, my references, and past and present employers and business and professional associates. It also includes information from federal, state, local or foreign government agencies. |
| I understand I must inform the department of any past, current or future criminal charges or convictions. I will also inform the department of any physical or mental conditions that jeopardize my ability to provide quality health care. If requested, I will authorize my health providers to release to the department information on my health, including mental health and any substance abuse treatment. |
| Field Name |
| 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? |
| 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? |
| 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism? |
| 4. Are you currently engaged in the illegal use of controlled substances? |
| 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| 6a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? |
| 6b. Diverted controlled substances or legend drugs? |
| 6c. Violated any drug law? |
| 6d. Prescribed controlled substances for yourself? |
| 7. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? |
| 8. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? |
| 9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid action by a state, federal, or foreign authority? |
| 10. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? |
| 11. Have you had hospital privileges, medical society, other professional society or organization membership revoked, suspended, restricted or denied? |
| 12. Have you ever been the subject of any informal or formal disciplinary action related to the practice of medicine? |
| 13. To the best of your knowledge, are you the subject of an investigation by any licensing board as to the date of this application? |
| 14. Have you ever agreed to restrict, surrender, or resign your practice in lieu of or to avoid adverse action? |
| 15. Have you ever been disqualified from working with vulnerable persons by the Department of Social and Health Services (DSHS)? |
| 1. Enter your National Provider Identifier (NPI) Number if available. |
| Are you the spouse or registered domestic partner of military personnel? |
| Field Name |
| First Name |
| Last Name |
| Date of Birth (mm/dd/yyyy) |
| Social Security Number |
| Gender |
| Street |
| City |
| Country |
| State |
| Zip Code |
| County |
| Phone Number |
| Cell Number |
| Email Address |
| Expiration Date |
| Issue Date |
| Text |
| There is a $2.50 convenience fee required to use the online service when paying by credit card/debit card. The amount will be charged in addition to your fee(s). There is no additional convenience fee for ACH payments. |
| Fees submitted with applications for initial credentialing, examinations, renewal and other fees associated with the licensing and regulation of the profession are nonrefundable. |
| Link |
| WAC 246-12-340. |
| Field Name |
| First Name |
| Last Name |
| Date of Birth (mm/dd/yyyy) |
| Social Security Number |
| Gender |
| Street |
| City |
| Country |
| State |
| Zip Code |
| County |
| Phone Number |
| Cell Number |
| Email Address |
| 1. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety? |
| 1a. Please explain medical condition. |
| 1b. Please explain how your treatment has reduced or eliminated the limitations caused by your medical condition. |
| 1c. Please explain how your field of practice, the setting or manner of practice has reduced or eliminated the limitations caused by your medical condition. |
| 2. Do you currently use chemical substance(s) in any way which impair or limit your ability to practice your profession with reasonable skill and safety? |
| 2a. Chemical Substance Explanation |
| 3. Have you ever been diagnosed with, or treated for, pedophilia, exhibitionism, voyeurism or frotteurism? |
| 3a. Diagnosis Explanation |
| 4. Are you currently engaged in the illegal use of controlled substances? |
| 4a. Controlled Substances Explanation |
| 5. Have you ever been convicted, entered a plea of guilty, no contest, or a similar plea, or had prosecution or a sentence deferred or suspended as an adult or juvenile in any state or jurisdiction? |
| 5a. Conviction Explanation |
| 6a. Possessed, used, prescribed for use, or distributed Controlled Substances or Legend drugs in any way other than for legitimate or therapeutic purposes? |
| 6a. Controlled Substance Legal Explanation |
| 6b. Diverted controlled substances or legend drugs? |
| 6b. Criminal Proceedings Explanation |
| 6c. Violated any drug law? |
| 6d. Prescribed controlled substances for yourself? |
| 6d. Self Prescribed Controlled Substance Explanation |
| 7. Have you ever been found in any proceeding to have violated any state or federal law or rule regulating the practice of a healthcare profession? |
| 7a. Violation of State or Federal Law Explanation |
| 8. Have you ever had any license, certificate, registration or other privilege to practice a healthcare profession denied, revoked, suspended, or restricted by a state, federal, or foreign authority? |
| 8a. License, Certificate, Registration Issue Explanation |
| 9. Have you ever surrendered a credential like those listed in number 8, in connection with or to avoid action by a state, federal, or foreign authority? |
| 9a. Surrender Explanation |
| 10. Have you ever been named in any civil suit or suffered any civil judgement for incompetence, negligence, or malpractice in connection with the practice of the healthcare profession? |
| 10a. Civil Judgement Explanation |
| 1. Enter your National Provider Identifier (NPI) Number if available. |
| Are you the spouse or registered domestic partner of military personnel? |
| State or Province |
| Profession |
| Credential Type |
| Credential Number |
| Issue Date |
| Expiration Date |
| Is this credential currently in an active status? |
| How did you receive this credential? |
| Timestamp | TestName | Status |
|---|---|---|
| Oct 27, 2022 06:58:49 PM | Validating the Intake Flow of Podiatric Physician And Surgeon License.4.Validate the HELMS portal Validations of Podiatric Physician And Surgeon License Intake flow - Podiatric Physician And Surgeon Limited License | pass |
| Name | Value |
|---|---|
| User Name | prince.gupta_mtxb2b |
| Time Zone | Asia/Calcutta |
| Machine | Windows 10 - 64 Bit |
| Selenium | 3.7.0 |
| Maven | 3.6.3 |
| Java Version | 1.8.0_151 |
| Name | Passed | Failed | Others | Passed % |
|---|---|---|---|---|
| @PodiatricPhysicianAndSurgeon1 | 1 | 0 | 0 | 100% |